Selective Mutism in the Selective Mutism in the Public School Setting:Public School Setting:

A Case StudyA Case Study

John F. Trembley, MSEd, CCC-SLPJohn F. Trembley, MSEd, CCC-SLPKingston City School DistrictKingston City School DistrictState University of New York, State University of New York,

New PaltzNew Paltz

This was once called: This was once called: Elective mutism:Elective mutism:

Continuous refusal to talk in most Continuous refusal to talk in most social situations, including schoolsocial situations, including school

An ability to speak and comprehend An ability to speak and comprehend spoken languagespoken language

(DSM-III, 3(DSM-III, 3rdrd edition, revised, APA, edition, revised, APA, 1987)1987)

Selective Mutism:

“Selective mutism is characterized by the appropriate use of language in certain settings, with total and persistent lack of language use elsewhere.”

(Giddan, et al, 1997)

Diagnostic Criteria for Selective Diagnostic Criteria for Selective MutismMutism

Consistent failure to speak in specific situations, Consistent failure to speak in specific situations, despite speaking in other situationsdespite speaking in other situations

The disturbance interferes with educational or The disturbance interferes with educational or occupational achievement or with social occupational achievement or with social communicationcommunication

Duration: at least 1 monthDuration: at least 1 month The failure to speak is not due to a lack of The failure to speak is not due to a lack of

knowledge of, or comfort with, the spoken knowledge of, or comfort with, the spoken language required in the social situationlanguage required in the social situation

The disturbance is not better accounted for by a The disturbance is not better accounted for by a Communication DisorderCommunication Disorder

(DSM-IV-TR, 2000, p. 127)(DSM-IV-TR, 2000, p. 127)

Our Student: Initial Profile:Our Student: Initial Profile:

CA: 11.8CA: 11.8Classified as a student with special Classified as a student with special

education needs…multiply disablededucation needs…multiply disabledPlaced in a 12:1:1 classroom 9/03Placed in a 12:1:1 classroom 9/03Received counseling, speech/language Received counseling, speech/language

services, occupational therapy servicesservices, occupational therapy servicesReceived informal diagnosis of “selective Received informal diagnosis of “selective

mutism” from previous school districtmutism” from previous school district

Communication behaviors on Communication behaviors on intake:intake:

Limited eye contact with classmates Limited eye contact with classmates and adultsand adults

Tendency towards solitary play Tendency towards solitary play behaviorsbehaviors

Pointing gestures to indicate requestsPointing gestures to indicate requestsOne word utterances characterized by One word utterances characterized by

minute lip movements with no minute lip movements with no vocalizationsvocalizations

Video segment:

A.B.’s communication

functioning—

June, 2004

The treatment plan:The treatment plan:

Utilizing components of the Socio-Utilizing components of the Socio-Communication Intervention Model Communication Intervention Model for Selective Mutism (Hungerford, et for Selective Mutism (Hungerford, et al, 2003)al, 2003)

Email consultation with program Email consultation with program authorauthor

Setting up a collaborative approach Setting up a collaborative approach with classroom teacher and parentswith classroom teacher and parents

Social-Communication Social-Communication Intervention Model for Selective Intervention Model for Selective

MutismMutism Accounts for nonverbal and verbal Accounts for nonverbal and verbal

components of social interaction as well as components of social interaction as well as speech & situation variables, includingspeech & situation variables, including

1.1. Eye contactEye contact2.2. Non-verbal turn takingNon-verbal turn taking3.3. Non-verbal indicators of joint attentionNon-verbal indicators of joint attention4.4. WritingWriting Encourages a scaffolded approach when Encourages a scaffolded approach when

manipulating variables during social manipulating variables during social interactioninteraction

(Hungerford, et al, 2003)(Hungerford, et al, 2003)

The Implementation of The Implementation of Therapy:Therapy:

Employed a scaffolded, task-Employed a scaffolded, task-analyzed approach, including:…analyzed approach, including:…

Communication modalityCommunication modalityCharacteristics of communicationCharacteristics of communicationPhysical environmentPhysical environment

Communication Modality:Communication Modality:

Pointing>>>writing>>>blowing on Pointing>>>writing>>>blowing on whistles>>>whispering>>>more whistles>>>whispering>>>more forceful, audible forceful, audible whispering>>>vocalizing whispering>>>vocalizing words>>>phrases>>>sentenceswords>>>phrases>>>sentences

Characteristics of Characteristics of Communication partners:Communication partners:

VERY FAMILIAR TO THE LESS FAMILIARVERY FAMILIAR TO THE LESS FAMILIAR……Familiar adultFamiliar adultLess familiar adult… Less familiar adult… Familiar peerFamiliar peerFamiliar peer groupFamiliar peer groupFamiliar peer group with unfamiliar Familiar peer group with unfamiliar

peer peer ClassroomClassroom

Physical Environment:Physical Environment:

Communication lab therapy roomCommunication lab therapy roomEmpty classroomEmpty classroomEmpty hallwayEmpty hallwayCrowded hallwayCrowded hallwayStructured classroomStructured classroomFree-time: classroomFree-time: classroom

Pragmatic language treatment in Pragmatic language treatment in group setting: group setting:

Social language skills targeted:Social language skills targeted: Identifying common categoriesIdentifying common categories Identifying comment types (opinion, Identifying comment types (opinion,

compliment, suggestion, insult, threat)compliment, suggestion, insult, threat)Using the telephoneUsing the telephone

Progress was assessed utilizing baseline Progress was assessed utilizing baseline and post-treatment checklists…and post-treatment checklists…

COMMUNICATION LAB PROGRESS CHART: A.B.--identifying common categories

73%

83%

68%

70%

72%

74%

76%

78%

80%

82%

84%

Oct-03 Nov-03 Dec-03

dates skill assessed

perc

enta

ge o

f cor

rect

resp

onse

s

Series1

COMMUNICATION LAB PROGRESS CHART: A.B .--identifying types of comments

30%

100%

0%

20%

40%

60%

80%

100%

120%

Oct-03 Nov-03 Dec-03 Jan-04 Feb-04

dates skill assessed

perc

enta

ge o

f cor

rect

resp

onse

s

Series1

COMMUNICATION LAB PROGRESS CHART: A.B.--telephone skills

33%

50%

0%

10%

20%

30%

40%

50%

60%

dates skill assessed

perc

enta

ge o

f cor

rect

resp

onse

s

Series1

To encourage increased breath To encourage increased breath support and more “forceful” support and more “forceful”

whispering—individual treatment whispering—individual treatment sessions including:sessions including:

Train whistles…requiring less air Train whistles…requiring less air expulsion to create noiseexpulsion to create noise

Tube noise makers…requiring more Tube noise makers…requiring more forceful air expulsion to extend tube, forceful air expulsion to extend tube, and yet more air force to create noiseand yet more air force to create noise

During these activities, clinician and During these activities, clinician and student would each have a whistle, student would each have a whistle, taking turns blowing and making taking turns blowing and making soundssounds

COMMUNICATION LAB PROGRESS CHART: A.B.--producing noise with tube noisemaker

0%

87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04

dates skill assessed

perc

enta

ge o

f suc

cess

ful n

oise

pro

duct

ions

Series1

Also during individual treatment sessions:

One-word whispers were modeled and practiced—louder whispers with increased breath support encouraged-

A.B. whispered one word utterances standing 10 ft. from the clinician

Intelligibility was assessed as percentage of words whispered correctly interpreted by the clinician…

COMMUNICATION LAB PROGRESS CHART: A.B.--percentage of intelligible one-word whisper productions

40%

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

dates skill assessed

perc

enta

ge o

f int

ellig

ible

whi

sper

pro

duct

ions

Series1

The transition to The transition to vocalization…vocalization…

A.B. came into school with a cold and A.B. came into school with a cold and was observed to be repeatedly clearing was observed to be repeatedly clearing his throathis throat

It was pointed out to A.B. that he used It was pointed out to A.B. that he used his voice when he cleared his throathis voice when he cleared his throat

During a subsequent session, A.B. and During a subsequent session, A.B. and clinician took turns purposely producing clinician took turns purposely producing throat-clearing vocalizations…this throat-clearing vocalizations…this practice limited to 5x per session practice limited to 5x per session

The transition to The transition to vocalization…vocalization…

A.B. encouraged to make throat-A.B. encouraged to make throat-clearing sound, immediately followed clearing sound, immediately followed by the word “hi”by the word “hi”

Throat-clearing behavior Throat-clearing behavior extinguished in one session, resulting extinguished in one session, resulting in a vocalized “hi” at a very low voice in a vocalized “hi” at a very low voice volumevolume

VocalizationVocalization

November, 2004—A.B. producing November, 2004—A.B. producing short phrases with phonation during short phrases with phonation during sentence repetition tasks in sentence repetition tasks in individual, then group sessionsindividual, then group sessions

December, 2004—A.B. produced 10 December, 2004—A.B. produced 10 spontaneous utterances with spontaneous utterances with phonation during individual sessionphonation during individual session

VocalizationVocalization

April, 2005—Classroom teacher reports A.B. April, 2005—Classroom teacher reports A.B. is producing average 2-3 utterances is producing average 2-3 utterances consisting of 2-3 words during a typical consisting of 2-3 words during a typical classroom activityclassroom activity

September, 2005—A.B. actively September, 2005—A.B. actively participating in classroom discourse utilizing participating in classroom discourse utilizing a normalized voice volume, freely joining in a normalized voice volume, freely joining in with classmates during free-time activities…with classmates during free-time activities…school staff has on occasion admonished school staff has on occasion admonished A.B. for inappropriately shouting out of turnA.B. for inappropriately shouting out of turn

Video segment:

A.B.’s communication

functioning—

June, 2005

Sources and suggested readings…Sources and suggested readings…

American Psychiatric Association (2000). American Psychiatric Association (2000). Diagnostic and statistical manual of Diagnostic and statistical manual of mental disorders (4mental disorders (4thth ed., text revision). ed., text revision). Washington D.C.: Author. Washington D.C.: Author.

Blum, N.J., Kell, R.S., Starr, H.L., Lender, W.L., & Osborne, M.L. (1998). Case Blum, N.J., Kell, R.S., Starr, H.L., Lender, W.L., & Osborne, M.L. (1998). Case study: Audio feedforward treatment of selective mutism. study: Audio feedforward treatment of selective mutism. Journal of the Journal of the American Academy of Child and Adolescent Psychiatry, American Academy of Child and Adolescent Psychiatry, 37, 40-43.37, 40-43.

Giddan, J.J., Ross, G.J., Sechler, L.L., & Becker, B.R. (1997). Selective mutism Giddan, J.J., Ross, G.J., Sechler, L.L., & Becker, B.R. (1997). Selective mutism in elementary school: Multidisciplinary interventions. in elementary school: Multidisciplinary interventions. Language, Speech Language, Speech and Hearing Services in Schools,and Hearing Services in Schools, 28, 127-133. 28, 127-133.

Harris, H.F. (1996). Elective mutism: A tutorial. Harris, H.F. (1996). Elective mutism: A tutorial. Language, Speech and Language, Speech and Hearing Services in Schools,Hearing Services in Schools, 27, 10-15. 27, 10-15.

Hungerford, S., Edwards, J., Iantosca, A. (2003, November). Hungerford, S., Edwards, J., Iantosca, A. (2003, November). A Socio-A Socio-Communciation Model for Selective Mutism. Communciation Model for Selective Mutism. Paper presented at the Paper presented at the meeting of the American Speech-Language-Hearing Association, Chicago, meeting of the American Speech-Language-Hearing Association, Chicago, IL.IL.

McInnes, A., Fung, D., Manassis, K., Fiksenbaum, L., & Tannock, R. (2004). McInnes, A., Fung, D., Manassis, K., Fiksenbaum, L., & Tannock, R. (2004). Narrative skills in children with selective mutism: An exploratory study. Narrative skills in children with selective mutism: An exploratory study. American Journal of Speech-Language Pathology, American Journal of Speech-Language Pathology, 13, 304-315. 13, 304-315.

Schum, R.L. (2003). Selective mutism: An integrated treatment approach. Schum, R.L. (2003). Selective mutism: An integrated treatment approach. The The ASHA Leader Online, 1-11.ASHA Leader Online, 1-11.